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APPLICATION <br /> trur Nan-Transferable,Revocable; and Suspendab.C, <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGF <br /> LIQUfu WASTE <br /> Application is hereby made to,carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> �;Business Name (DBA) P,Q �N S <br /> 'a Owner Address P0. <br /> Firm Partners, Addresses and Telephone Numbers Address <br /> IL <br /> Business Telephone No. — <br /> jj Contractor Licence No. Emergency Teleehone No. <br /> L Applicants Name (Print) s <br /> o TitleLr15.�8-� _ pate <br /> Please check Applicable Cate E <br /> g ry(1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE ARMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> f <br /> Description(Make/Yr„ Color) <br /> Serial No, CAL, License No. <br /> Capacity CAL. License Renewal No, <br /> Gal., Weights & Measures No. <br /> Equipment Parking Address. <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. Of Vehicles Stored <br /> No. of Chemical Toilets Stored _ <br /> 3• ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> R.S. or R.C.E. No. <br /> Te �Location -- <br /> 4. SANITATION PERMIT Test Date/Time <br /> Job Address/Location <br /> Ow er Address i <br /> EPT1C TANK ❑ CESSPOOL LEACHING FIELD p <br /> PERMANENT ❑ TEMPORARY NEW <br /> SEEPAGE PIT El PLANT <br /> ❑ REPAIR ❑ OTHER ` ICS,_ 1 Thr, �'' <br /> 5. 13 CHEMICAL TOILETS For July 1, -Jurie 30, 19 <br /> Type Construction <br /> No. of Units Disposal Site <br /> EquipmenYStorag e/Cleaning Location(s)' r <br /> 6. ❑ PACKAGE TREATME=NT PLANT For July'1, -"June 30, 19 + � <br /> Operator Name . <br /> Plant Location re Cern led <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1,'-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ EWY CLEANING, Chemicals Used/Amount/Mo. <br /> e+rlewnrrMrorlice'nr:adage,nAAitIf: ecer�►tte,mgfollowing.,.t"flify <br /> that inthe per1errtr o8 Of the�yorkfor wrhfchf#risperrnitisissued,Ishall"Of emplevan er^ <br /> in such manner as io become suiriecl If: tiork;n�3,,co�Ror;afiun IdNJ5 otCaliforrria - <br /> .1von1raClnr's Kirin« or ,uh-co»tner.isnr� sig n;�tvrp:eprfifies the i<�iloUldp <br /> employ persons subject to v+ur<rnan's cernNjrlsation laws o1 Camo[Ilia, a "i cerify that In t11g ptsrformance of the wmrk y p Jon <br /> • :.. . ..,• .. .I ,hall <br /> I hereby certify that I have prepared this application and tha t e work will be done in accordance with San Joaquin County <br /> ordinances, state laws les_and r ulations. the a J aq Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By Janu5� <br /> ary 31 July 1 8 Received By July 31 - <br /> BASE EXPLANATION BILLING REMITTANCE - $ REMIT <br /> / DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS v <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER }~ I <br /> OTHER - p <br /> Received by Date / <br /> Receipt No. P rmit No. <br /> issuance Date <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Mailed Delivered - <br /> - 1601 E.HAZELTON'AYE.,P.O.Box 2009 STOCKTON,CA 95201 !t <br />